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Workshop/Breakout Title
Workshop/Breakout Speaker(s)
Changes in Infant Death Coding and Implications for Safe Sleep Campaigns
Malinda Douglas, MPH, Oklahoma Department of Health Violanda Grigorescu, MD, MSPH, Michigan Dept. of Community
HealthSandra Frank, JD, CAE, Tomorrow's Child/Michigan SIDS
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Sleep-Related Deaths Among Infants in
Oklahoma, 2000-2003
• Malinda Reddish Douglas, MPHTobacco Use Prevention Service, OSDH
• Pam Archer, MPHInjury Prevention Service, OSDH
• Jeff Gofton, MDOffice of the Chief Medical Examiner
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Background
• Each year, 400 infants under 1 year old die in Oklahoma– 22% congenital and chromosomal
abnormalities– 13% disorders related to premature birth– 9% sudden infant death syndrome
• Death rate decreased 7%– 2000: 8.4/1,000– 2003: 7.8/1,000
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Introduction
• Oklahoma Chief Medical Examiner noticed increase in co-sleeping deaths
• Child Death Review Board and Department of Human Services concerned with increase in co-sleeping deaths
• SAFE KIDS Coalition and other partners began development of SIDS – safe sleep materials
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Unsafe Sleeping Environment
• Prone sleeping• Exposure to secondhand smoke• Sofas, chairs, loveseats• Soft bedding, pillows, quilts,
blankets• Entrapment hazards• Co-sleeping?
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Co-Sleeping Recommendations
Discourages Cautions Encourages
•CPSC •AAP •Attachment parenting groups
•Child death review boards
•NICHHD •La Leche International
•SIDS Alliance
•Some health departments
•Mother-Baby Sleep Laboratory
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2000 National Data on Nighttime Infant Bed Sharing with Adults
• Prevalence– 13% entire night
• Up from 6% in 1993
– 20% half of the time or more– 45% some time during past two weeks– Twice as likely as to be covered by quilt or
comforter– Most common in mothers < 18 years, low
income, non-white, and infants < 8 weeks
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Potential Reasons for Co-Sleeping
• Bonding• Breastfeeding• Cultural practice• Fear of SIDS• Fear of not hearing the baby• Baby sleeps better• Parents sleep more• No crib
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Sleep-Related Infant Death Study
• Purpose – Investigate infant deaths– Characterize sleeping practices– Determine co-sleeping trends over
time
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Medical Examiner System
• Investigate deaths under certain circumstances
• Determine manner of death (intention)
• Determine cause of death
• Statewide system
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Methods
• Analyzed Medical Examiner database– January 2000 through December 2003– Oklahoma residents– Less than 12 months of age– Manner of death = Accidental
– Cause = Asphyxia
– Manner of death = Unknown– Cause = Asphyxia– Cause = Other– Cause = Unknown
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Methods
• Reviewed reports of investigation– Demographic data– Details of the death– Narrative of circumstances– Autopsy report
• Last known activity was sleeping
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Definitions
• Unsafe sleeping– Not sleeping alone in a safe crib or bassinette– Not put to sleep on back or found on back– Pillows, stuffed toys, loose quilts or comforters
• Co-sleeping– Sharing a sleep surface with another person– Surfaces include bed, couch, chair, and other
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Unsafe Sleeping Case Selection
• 124 possible cases reviewed• 113 infants sleeping prior to death
– 2 following safe sleep guidelines– 5 lacked specific details to classify
• 94% (106/113) involved unsafe sleeping conditions– 81% unknown manner of death– 80% other/unknown cause of death
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Unsafe Sleeping Deaths by Age and Sex, Oklahoma,
2000-2003
0
5
10
15
20
25N
um
ber
of
case
s
0 1 2 3 4 5 6 7 8 9 10 11
Age in months
Females Males
Source: Oklahoma State Medical Examiner, n = 106
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Unsafe Sleeping Deaths by Race and Year, Oklahoma,
2000-2003
0
5
10
15
20
25
30
35N
um
ber
of
death
s
2000 2001 2002 2003
Year of death
African American American Indian White
Source: Oklahoma State Medical Examiner, n = 104, excludes 2 cases coded as other
Rate/1,000
AA: 1.2
AI: 0.7
W: 0.4
Overall: 0.5
* includes Hispanic
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Time and Place of Occurrence
• 82% at night
• 97% occurred in a private home– 86% in own home– 11% in others home
• 2% in licensed child care
• 1% in hospital
Source: Oklahoma State Medical Examiner, n = 106
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Unsafe Sleeping Deaths by Sleep Surface, Oklahoma,
2000-2003
Bed50%
Couch8%
Crib13%
Unknown/ Other12%
Mattress on floor5%
Playpen5%
Waterbed3%
Bassinette4%
Source: Oklahoma State Medical Examiner, n = 106
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Unsafe Sleeping Deaths by Mechanism of Injury,
Oklahoma, 2000-2003
Overlay - definite
6%Pillow
8%
Unknown/ Other33%
Overlay - possible
31%
Blanket6% Entrapped
10%
Found on floor6%
Source: Oklahoma State Medical Examiner, n = 106
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Infant Health History
• Breastfed – 6%– 74% not specified
• Low birth weight – 6%– 87% not specified
• Premature birth – 15%– 56% not specified
• Respiratory illness – 25%– 68% not specified
Source: Oklahoma State Medical Examiner, n = 106
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Caregiver or Family Factors
• Use of alcohol and/or drugs – 14%
• History of drug/alcohol problems – 11%
• CPS involvement – 21%
• Previous SIDS death – 3%
• Secondhand smoke exposure – 3%
Source: Oklahoma State Medical Examiner, n = 106
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Unsafe Sleeping Deaths by Co-Sleeping at the Time of
Death, Oklahoma, 2000-2003
0
5
10
15
20
25
30
35
Num
ber
of
death
s
2000 2001 2002 2003
Year of death
Co-sleep Not co-sleep
Source: Oklahoma State Medical Examiner, n = 103, excludes 3 unknowns
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Co-Sleeping Deaths by Age and Sex, Oklahoma,
2000-2003
0
2
4
6
8
10
12
14
16
18
20
Num
ber
of
dea
ths
0 1 2 3 4 5 6 7 8 9 10 11
Age in months
Female Male
Source: Oklahoma State Medical Examiner, n = 68
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Surface and Co-sleep
• 71% on bed
• 9% on couch/chair/love seat
• 6% mattress on floor
• 4% on waterbed
• 1% in crib (sleeping with twin)
• 9% all other/unk combined
Source: Oklahoma State Medical Examiner, n = 68
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Co-sleepers Deaths by Mechanism of Injury,
Oklahoma, 2000-2003• 55% possible/definite overlay
• 4% entrapped
• 3% pillow
• 6% found on floor
• 1% other
• 31% not specified
Source: Oklahoma State Medical Examiner, n = 68
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Factors Present When Cases Lacked Details on
Possible Mechanisms• 33% open or history of CPS
involvement
• 19% staying at someone else’s home
• 10% previous apnea episodes
• 10% face down on mattress
• 5% waterbedSource: Oklahoma State Medical Examiner, n = 68
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Co-sleeping Characteristics
• Number co-sleeping– 50% two sleeping together– 40% three sleeping together– 10% four sleeping together
• Classification of sleeper– 73% adult(s)– 18% child(ren)– 9% adult(s) and child(ren)
Source: Oklahoma State Medical Examiner, n = 68
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Medical Examiner Interview
• Infant deaths increasing• Co-sleeping deaths increasing
– Mainly among the white population
• Beliefs, opinions, and experiences reflected in reporting
• Budget cuts in 2003– May have resulted in change in coding
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Infant Deaths by Selected Cause, Oklahoma,
2000-2003Database/Cause 2000 2001 2002 2003
VS – all infant #
(Rate/1,000 births)
420
(8.4)
362
(7.2)
406
(8.1)
395
(7.8)
ME – all infant #
(Percent of VS infant deaths)
216
(51%)
222
(61%)
248
(61%)
278
(70%)
ME – unsafe sleep #
(Percent of ME infant cases)
21
(10%)
23
(10%)
17
(7%)
47
(17%)
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ME Investigated Infant Deaths by Selected Cause,
Oklahoma, 2000-2003
0
10
20
30
40
50
60
2000 2001 2002 2003
Year
Num
ber
of
death
s
ME unsafe sleep ME SIDS
Source: Oklahoma State Medical Examiner
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Conclusions
• Unsafe sleep deaths– Most were infants < 3 months of age
– Half occurred in beds
– Unsafe items used in cribs and bassinettes
– Mechanism of injury varied by age
• Co-sleep deaths– Increase in co-sleeping deaths
– Increase among whites
– Not clear if due to artifact of coding
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Limitations
• Non-standardized documentation• Medical Examiners and
investigators limited by informants • Distinguishing SIDS from other
causes• Budget cuts to the Medical
Examiner
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Discussion
• Other States have similar trends
• Cultural issue
• Distinguishing SIDS from overlay
• Coding of undetermined cause or intent
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Recommendations
• Education campaign for businesses– Crib displays in
stores that show safe sleeping environments
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Recommendations
• Increase awareness of co-sleeping deaths• Promote consistent safe sleeping practice
messages through collaborative efforts– Same safe sleeping environments can reduce
risk factors for overlay, SIDS, and asphyxia
• Messages that resonate with target populations
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Questions?Questions?